PERFECT = PERFormance, Effectiveness and Cost of Treatment episodes http://www.terveytemme.fi/perfect/ http://www.thl.fi/fi_FI/web/fi/tutkimus/hankkeet/perfect 19.9.2018

GENERAL AIM OF PERFECT To develop methods for register-based measurement of the cost-effectiveness of treatment and to create a comparative database that allows the treatments given and their costs and outcomes to be compared between hospitals, hospital districts, regions and population groups. 19.9.2018

Costs and Outcomes Health care system Determinants of a disease Pre-stage of a disease Acute stage of a disease Chronic stage of a disease Costs and Outcomes Health care system Economic resources Incentives Medical knowledge 19.9.2018

PERFECT Produces comparative information on treatments and their costs and outcomes for treatment monitoring and development. Creates indicators and models for monitoring the content, quality and cost-effectiveness of treatment episodes in specialised medical care. Assesses factors that influence costs and outcomes. Develops methods for the register-based measurement of cost-effectiveness, and comes up with proposals concerning the data content of national level registers in order to improve the continuous monitoring of cost-effectiveness. Develops an approach and methodology that can be subsequently applied to other disease groups as well. Compares costs and outcomes at an international level 19.9.2018

PERFECT - disease groups The focus will be on selected disease groups with sufficient significance in terms of costs and burden of illness: Acute myocardial infarctions, extended later to revascular procedures (CABG, PTCA) Hip fracture Breast cancer Hip and knee replacements Very low birth weight infants Schizophrenia Stroke 19.9.2018

Organisation of the Project Each subprojects has own expert group, together 50 clinical experts Develop the disease/health problem specific protocols Define the content of data Is responsible for basic reports Aims to do international comparison THL / CHESS is responsible for overall coordination of the project, gathering and analysing the data and for health economic, health service research and statistical expertise 19.9.2018

Description of PERFECT-Project BASIC REPORTS THL Hospital discharge register, Hospital productivity (Benchmarking) database SOCIAL INSURANCE INSTITUTION Register on Health and Social Benefits STATISTICS OF FINLAND Cause-of-Death Register OTHER REGISTERS Implant Register on Orthopaedic Endoprostheses, Hospitals patient registers RESEARCH PERFECT DATA BASE FEEDBACK 19.9.2018

Content of basic reports http://www. thl Levels Hospital Districts (responsible for providing specialist care in Finland) based on the municipality of the patient) Hospitals (over 50 patients), based on patients treated in a hospital Indicators Basic information on patients such as number of patients, age structure, co-morbidity (about 40 indicators) Process indicators describing length of stay, outpatient visits, use of procedures, drugs, cost of care (about 140 indicators) . Indicators describing outcomes of patients (about 60 indicators) 19.9.2018

Current status of Perfect Acute myocardial infarction (regional level and hospital data available from the years 1998-2011/2013) Hip Fracture (regional and hospital level data available from years 1999-2011/2013) Hip and knee replacements (regional and hospital level data available from years 1998-2013) Very low birth weight infants (regional and hospital level data available from years 2000-2012) Schizophrenia (regional and hospital level data available from years 1995-2001 cohorts) Stroke (regional and hospital level data available from years 1999-2011/2013) 19.9.2018

Key questions Definition of an episode: When it starts and when it finishes (follow up time)? Balancing: what can be done on routine basis with scientific/methodological aspects 19.9.2018

Definitions of the episodes Admission to ward A Procedure/treatment in ward A Admission to ward B Discharge to another hospital Outpatient visit Medication purchase Total episode of care First hospital episode time Discharge home or nursinghome 19.9.2018

Solutions used in basic reports 1) A definition of patient group so that that they are as comparable as possible Examples New hospitalised AMI (ICD-10 I21-I22) aged 40-85:Patients were excluded if i) they were discharged alive and had a length of stay, including transfers, of less than 3 days, ii) they had been hospitalised for AMI during the previous year (365 days) iii) if the were institutionalised before hospital admission for AMI Stroke. First ever stroke and not institutionalised 2) Risk adjustment for co morbidity using information on previous use of hospital inpatient care (since 1987), registered individuals suffering from certain specified chronic conditions (Social insurance institution) and purchases of prescribed medicines 3) Standardising by modelling and calculation of confidence intervals 19.9.2018

Measurement of outcome So far mostly risk adjusted traditional measures (7 day, 30 day, 1 and 5 year) mortality, infections, readmissions, reoperations, days until return to home, days spent at home in during follow up (e.g. one year) placement in long-term care 19.9.2018

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Measurement of cost Estimation of standard (relative) cost for each outpatient visit and inpatient discharge in the database Based on patient level cost data in one hospital district. Assumes that unit cost of producing specific procedures or DRGs are same all over country in each year Cost of prescribed drugs based on their retail prices 19.9.2018

Measurement of cost in basic reports Cost and utilisation data for all inpatient care, outpatient visits in specialised care and private doctors’ visits and prescribed medicines Standardisation modelled using GLM (log link with gamma distribution). Two or three part model for cost of prescribed medicines. Deaths or survival time included in standardisation 19.9.2018

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Next steps Extending the approach to primary and social care Pilot project in capital area and municipality of Kouvola (about 1.2 million parsons) Data 2006  Sub projects Children Psychiatric patients Elderly Substance abusers. Comparison with Oslo and Stockholm 19.9.2018

One year cost (EUR) of stroke patients, 2009-2010 19.9.2018

Challenges Reporting of secondary diagnosis and procedures Time lag, reliable comparison need pooled 2-3 years data Development of quality registers? Under discussion Development of Patient Data Repository system, under current legislation not possible to use for research and statistics 19.9.2018

Extension of Perfect: EuroHOPE 19.9.2018

Partners Centre for Health and Social Economics (CHESS),National Institute for Health and Welfare, Finland Centre for Research on Health and Social Care Management, Universita Commerciale Luigi Bocconi, Milano, Italy Health Services Management Training Centre, Semmelweis University, Budapest, Hungary National Institute of Public Health and the Environment, the Netherlands University of Oslo, Department of Health Management and Health Economics, Norway Ragnar Frisch Centre for Economic Research, Oslo, Norway University of Edinburgh, Scotland Medical Management Centre (MMC), Karolinska Institutet, Stockholm, Sweden 19.9.2018

Patient group specific work in EuroHope (I) Five patient groups subject to acute myocardial infarction (AMI) stroke hip fracture breast cancer very low birth weight infants Clinical experts from each of the participating countries The protocols define inclusion/exclusion criteria definition of cycle of care (when it starts, follow-up etc.) comorbidities (used in risk adjustment) specification of outcome measures 19.9.2018

data used for comparative research EuroHOPE Data Comparison of countries, regions and hospitals EuroHOPE research National EuroHOPE database National EuroHOPE compari-son data International EuroHOPE comparison data National discharge register National mortality register Other national registers Protocols Anonymous individual level data used for comparative research National research and bencmarking 19.9.2018

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Regional variation in mortality, AMI Age- and sex-adjusted one-year mortality by regions, AMI in 2008 (2009 in Norway). AMI: most of the Italian and Swedish and all the Norwegian regions performed better than average regions for all countries in one year mortality, whereas some Finnish, most of the Scottish and all the Hungarian regions performed poorer than average The use of PCI had a negative but not statistically significant effect at the regional level. 19.9.2018

Regional variation in mortality, hip fracture Age- and sex-adjusted one-year mortality by regions, hip fracture in 2008 (Norway 2009) In hip fracture, well-performing regions were found—in addition to Italy and Sweden—from Norway Regarding ischaemic stroke and hip fracture patients, the regional differences in length of stay and mortality were not related to any of the analysed regional level factors. 19.9.2018

Measurement of hospital quality performance (30-day survival) Empirical Bayes estimates of hospital effects for quality obtained from a model, where age, gender, comorbidities and transfers to a higher level hospital are taken into account The effects do not as such have exact practical interpretation but we can estimate that survival difference between the lowest and highest hospital was 30 percentage points (min 67.5, max 97.5) in the care of AMI patients Stockholm 8.04.2014

Measurement of hospital quality performance (30-day survival) Empirical Bayes estimates of hospital effects for quality obtained from a model, where age, gender, comorbidities and transfers to a higher level hospital are taken into account The effects do not as such have exact practical interpretation but we can estimate that survival difference between the lowest and highest hospital was 30 percentage points (min 67.5, max 97.5) in the care of AMI patients Stockholm 8.04.2014

Hospital-level comparison: Measurement of hospital quality performance (30-day survival) Empirical Bayes estimates of hospital effects for quality obtained from a model, where age, gender, comorbidities and transfers to a higher level hospital are taken into account The effects do not as such have exact practical interpretation but we can estimate that survival difference between the lowest and highest hospital was 30 percentage points (min 67.5, max 97.5) in the care of AMI patients 19.9.2018

Hospitals cost performance in care of AMI patients based on empirical Bayes estimates of random coefficient 19.9.2018

EuroHOPE now and future Maintains national and regional indicators at http://www.eurohope.info Provides audience with scientific and policy relevant results Health Policy articles – 2 pieces on the air already! Health Economics Supplement – Beginning of 2015 Variety of clinical articles – 4 papers submitted Stream of publications in EuroHOPE Discussion Papers Series at www.eurohope.info Continues the performance evaluation and extends the activity to other countries and other patient groups. BRIDGE project: updating the data from Finland, Sweden, Norway, Italy, Hungry and Denmark. CanHOPE. Nordic comparison including socioeconomic data (Finland, Norway) 19.9.2018